INNOVATIONS IN Measuring Value Bob Pendleton, MD, FACP David Dirks Chief Medical Quality Officer AVP, Population Health Analytics University of Utah Intermountain Healthcare
Understand the importance of culture in using measurement to improve value Share innovative approaches to measure Objectives value for episodic care across a full care cycle Illustrate innovative population approaches to measure and improve value
THE GOLDEN CIRCLE WHAT Every organization on the planet knows WHAT they do. HOW Some organizations know HOW they do it. WHY Very few organizations know WHY they do what they do. (Sinek, S. Start With Why. 2009)
THE GOLDEN CIRCLE CLARITY OF WHY. An absolute focus on the patient DISCIPLINE OF HOW. Patients define value (clinical population) & Respect for people (bottom up solutions) CONSISTENCY OF WHAT. Methods/approaches that support better outcomes at an affordable cost (Sinek, S. Start With Why. 2009)
MEASURING VALUE + VALUE ACCOUNTABILITY FOR VALUE QUALITY PATIENT OUTCOMES AND COSTS DEFINED AND MEASURED PATIENTS VALUE STREAM: FULL CARE CYCLES PROCESSES OF CARE; FEW OUTCOMES NO UNDERSTANDING OF QA ACTUAL COSTS - ENCOUNTER-CENTERED RISK-BASED EVENTS *Size of bubble = $ and/or reputation risk Pre-2000 2000-2015 2016+++
MEASURING VALUE Total Cost of Care Total cost of care & Patient Centered and PCOs Outcomes (PCOs) Provider Cost PQRS + MU - EP MIPS Common Provider Quality Provider Quality OQR + HEDIS Core Ambulatory Quality Ambulatory Quality IQR + MU - EH Hospital Cost Hospital Cost Hospital Service Hospital Service Hospital Quality Hospital Quality Hospital Quality QA/Risk QA/Risk QA/Risk QA/Risk Pre-2000 2000-2010 2010-2015 2016+
MEASURING VALUE APM Care Integration Required ALTERNATIVE PAYMENT APM PROVIDER RISK MODEL (APM) (population APM Based risk) (risk bearing, FEE FOR built on FFV VALUE (FFV) architecture) (ties to quality/cost Performance) FEE FOR FFV SERVICE (FFS) (no ties to performance) FFS Current State Proposed 2018 (Based on Figure 3. Alternative Payment Model (APM) Framework: Final white paper. HCPLAN, p. 9, 2016.)
“… A fundamental and largely unrecognized problem: We don’t know what it costs to deliver health care to individual patients, much less how those costs compare to the outcomes achieved.” “Understanding costs could be the single most powerful lever to transform the value of health care.” - Robert S. Kaplan & Michael E. Porter
MEASURING VALUE 1. Define actual costs of care at patient level 2. Organize data around clinical conditions 3. Engage providers to define outcomes 4. Foster peer-to-peer transparency to explore variation 5. Empower & support improvements in value (David Browdy, CFO, University of Utah Health Sciences 2015)
MEASURING VALUE E. REPORTS AND DASHBOARDS Opportunity Variance Performance Identification Analysis Tracking C. COST BUSINESS USED BY RULES B. ENTERPRISE DATA Rules for Identifying Direct D. OUTCOME Clinical Care Costs with WAREHOUSE BUSINESS RULES General Ledger USED USED Encounter-Level Encounter & Patient-Level Costs Quality & Outcomes Cost Methods Quality/Outcome BY BY Rules Clinical and Financial Designation of Cost Methods Data Marts to Use for Allocating General Ledger Direct Clinical Care Cost Encounters POPULATE A. DATA SOURCES Clinical Data Financial Data Sources Sources (Kawmoto, K et al. JAMIA 2014)
O.R.C.A. Supply Usage by Case (Value Driven Outcomes Screen Capture)
VALUE DRIVEN OUTCOMES Billing Provider Professional Dept. Expenses costs added in 2014 Dept. Staff AVERAGE COST PER Facility Utilization Lab Other Services Pharmacy VISIT Radiology Supplies Source: Average hospital cost per visit, Discharges 2012-2014
VALUE DRIVEN OUTCOMES Higher Quality Drives Low er Cost PERFECT CARE INDEX AND AVERAGE COST Outcome: Perfect Care % to FY12 Average Cost % to FY12 Average Cost Quality Index 33% COST SAVINGS Discharge Month Quality Index: Percentage of all visits where selected care measure was met (Pelt 2016) % to FY12 Average Cost: Ratio of that months avg. cost compared to baseline 2012 avg. cost
VALUE DRIVEN OUTCOMES Reduce resource use across clinical conditions without decreasing quality. Examples: • Reduce lab use by 10% 3 Reduce telemetry use by 20% 4 • • Standardize bronchodilator RX use: $248k/yr Improve value of procedural based care and/or within clinical conditions. Examples: TJA: cost decreased by 33%, increase quality 2 • Soft tissue infection: cost decreased by 13%, increase quality 5 • • Renal Transplant: $408k annual savings, maintain quality
VALUE DRIVEN OUTCOMES Current measurement emphasis on quality focuses on processes and complications of care— to patients, these are expectations. Outcomes are the ultimate measure by which to judge quality— whether or not care actually helps the patient (or their families). PROs have been validated as disease-specific measures (e.g. DASH), generic outcome measures (e.g. SF-36), and domain specific measures (e.g. PROMIS) The Ideal Solution: 1. Patient/user friendly, reliable, valid, integrated, and scalable solution to assess outcomes across a broad range of patient conditions; 2. Able to assess this in the context of both direct care provision as well as costs-of- care and other quality metrics
VALUE MEASUREMENT
VALUE MEASUREMENT With Epic integration, we are able to compare patient progress to historical trends.
VALUE MEASUREMENT
VALUE MEASUREMENT Managing Population 1 Organized around clinically defined conditions and diseases 2 Provide clear standards of care for treatment 3 Built on a knowledge management infrastructure 4 Identify key roles and responsibilities to carry out standards of care 5 Integrate directly into workflow with focus on usability 6 Provide consistent attribution of members and patients to the appropriate care-giver 7 Provide feedback to all stakeholders on performance
Person-Level Data Person-Level Data Clinical Data Claims Data Financial Data Patient Reported • Wellness Data • Problem List • Utilization • Demographics • Demographics • Labs • Premiums • Diagnosis/Procedure • Family Hx • Vitals • Total Cost Codes • Etc. • Etc. • Etc. • Billing Data • Etc.
Know ledge Management Core Knowledge Management Core Patient Care Actionable Cohorts Modules Care Gaps Person-Level Data Source
Patient Data Interaction Payers and Employers Members & Families Clinics & Physicians Hospitals Knowledge Management Core
Patient Data Interaction Care Managers Payers and Employers Members & Families Clinics & Physicians Hospitals Knowledge Management Core
Patient Data Interaction Care Managers Payers and Employers Members & Families Clinics & Physicians Hospitals Patient Portal Workflow Workflow Knowledge Management Core
Patient Data Interaction Care Managers Payers and Employers Members & Families Clinics & Physicians Hospitals Patient Portal Workflow Workflow • Decision Support Data • Decision Support Data • Decision Support Data • Care Gaps • Care Gaps • Care Gaps • Attribution • Attribution Knowledge Management Core
“Our most important data is where the patient is today and where the patient needs to be tomorrow.” “I want to encourage all of us to pause and give thought to this: Can we transform healthcare and change the data focus from big data to actionable data that connects people, their teams and their care plans?”
Patient Data Interaction Care Managers Payers and Employers Members & Families Clinics & Physicians Hospitals Patient Portal Workflow Workflow • Decision Support Data • Decision Support Data • Decision Support Data • Care Gaps • Care Gaps • Care Gaps • Attribution • Attribution Reports Reports Reports Reports Knowledge Management Core Reporting is based on adherence to defined standards not variation between providers
Performance Measurement HOW WELL AM I CARING FOR MY PATIENTS? Quality Measurement Dashboard
Patient Engagement & Q.I. HOW CAN I IMPROVE THE HEALTH OF MY PATIENT POPULATION? Patient-Level Gap Reporting
Cost & Utilization Management AM I CARING FOR MY PATIENT POPULATION AT A REASONABLE COST? Cost & Utilization Analysis
Thank you. Bob Pendleton, MD, FACP David Dirks Chief Medical Quality Officer AVP, Population Health Analytics University of Utah Intermountain Healthcare
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